<html>
<head>
<title>Dashboard</title>
<style type="text/css">
body {
background-image: url(assets/img/bg_center.jpg);
}

#container_1 {
width: 360px;
height: 500px;
margin: 100px 50px;
background: #fff;
color: #000;
}

#container_2 {
width: 660px;
height: 500px;
margin: 100px 5px;
background: #fff;
color: #000;
}
</style>
</head>

<div style="text-align: center"><font color="#FFFFFF"><strong><h1>Dr. Smith's Readmission Dashboard</h1></strong></font></div>

<body>

<table>
<tr>

<!--  Input Forms   -->
	<td>   
		<div id='container_1', width: 260px;>
			
			<form action="index.php" method="post"> 
   			<p> Patient Name: <input type="text" size="20" name="pname"><br>
   			Gender: 	<select name="gender">
  				 				<option value="M">Male</option>
  					 			<option value="F">Female</option>
   						</select><br>
   			Patient Age: <input type="text" size="20" name="page"><br>
   			Primary Diagnosis: <select name="pdis">
   									<!--value should match diagnosis icd code from our data source-->
   											<option value="123">Heart Disease</option> 
   											<option value="453">Diabetes</option>
   											<option value="111">Other</option>
   									</select><br> </p>
<input type="submit" value="Add Patient">
<input type="reset" value="Clear">
</form>

			
			
			
			
			
		</div>
	</td>

<!--  Patient Table Data   -->
	<td> 	
		<div id='container_2'>
			Right
		</div> 
	</td>
</tr>
</table>

</body>
</html>